What is a Coverage Determination?
A coverage determination is a decision that we make about your benefits and coverage, or about the amount we will pay for a prescription drug. A coverage determination is requested when you ask us to cover your Part D drug even if it is not on our formulary or waive certain restrictions that are placed on your Part D drug, or provide a higher level of coverage for your Part D drug. You, your doctor or prescriber, or an appointed representative may contact us to request a coverage determination.
What restrictions could be placed on my drugs?
As you review your formulary you may notice that certain drugs show symbols next to them, such as PA, ST, or QL. These symbols stand for additional requirements or limits on that drug:
- Prior Authorization (PA): You or your doctor or prescriber must ask Granite Alliance for approval before we will agree to cover the drug.
- Step Therapy (ST): We ask that you try one or more alternative drugs before we can cover the drug requested. The alternative drugs are generally less costly but just as effective.
- Quantity Limit (QL): A limit on the amount of the drug that you can have each time you fill your prescription. Generally, this limit is based on U.S. Food & Drug Administration (FDA) requirements on how much is considered safe to take per day.
If you need a drug that has a PA requirement, or if your doctor or prescriber wants us to make an exception to the ST or QL requirements, then you, your doctor or prescriber, or an appointed representative can ask us to make a coverage determination.
How do I request a Coverage Determination?
You, your doctor or prescriber, or appointed representative may file your coverage determination request by phone, mail or fax. Your coverage determination can be requested 24 hours a day, 7 days a week. You can also submit your coverage determination request online.
Call Us: 855-586-2573 (TTY: 711)
When you mail or fax your request, we recommend printing off our Coverage Determination Request form to ensure you are providing all the information needed for us to process your request.
Mail the Request: Granite Alliance P.O. Box 1382 Maryland Heights, MO 63043
Fax Us: 1-888-656-8099
What happens when I request a Coverage Determination?
Once Granite Alliance receives a coverage determination request, we immediately review the information you provided, plus any additional information we received from your doctor, prescriber or pharmacy. If your request is a standard coverage determination about a drug you have not yet received, once we receive your request, we have 72 hours to make our decision. We will give you the decision sooner if you have not received the drug yet and your health condition requires us to. If you already bought your drug and are asking us to pay you back, we must make our decision within 14 calendar days after we receive your request.
You may also request an expedited coverage determination which means we will give you a decision within 24 hours. You may get an expedited coverage determination only if you are asking for a drug you have not yet received; and you, your doctor, or prescriber indicate that waiting 72 hours could seriously harm your life or health or hurt your ability to function.
A type of coverage determination is called an “exception”. If a drug is not covered in a way you would like it to be covered, you can ask us for an exception. To request for an exception, we must receive a statement from your doctor or prescriber explaining why the drug you are asking for is medically necessary. Once we receive your statement, we will then consider your request. We will reach out to your doctor or prescriber on your behalf if we do not receive the statement with the initial request.
Once we make a decision, we will let you know whether we have approved or denied your request. We work closely with your doctor or prescriber to make sure we have all the information we need to approve your request. However, there are times when we may deny your request. The most common reasons for denial are:
- Your doctor or prescriber did not give us all the information we need.
- Your doctor or prescriber may switch you to another drug on the formulary.
- The requested drug is excluded from Part D coverage.
- The requested drug is not being used for the correct condition.
If we deny your request, we will provide you with a detailed explanation in a letter. The letter will contain information such as other covered drugs that you can discuss with your doctor or prescriber, criteria that was and was not met, and next steps. If you disagree with our decision, or if your doctor or prescriber has additional information, you can contact us to appeal our decision (called a “Redetermination Request”). Learn more about the appeals process.
For additional information on the coverage determination process, please review Chapter 6 of your Evidence of Coverage.